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Prader-Willi Syndrome Association (SA) membership application form

Should you wish to join PWSA (SA), please fill in the the form below. Alternatively you can print this page out, fill it in and post it to: Wilna, PO Box 2399, Brooklyn Square, 0075 or fax to 086 551 5980. We will supply the banking details when we receive the form.

All information supplied is treated confidentially!

Please note the following fees:
Registration - R50 (once off)    Annual - R200 (in SA)    R220 (outside SA)

PARENTS' INFORMATION  
Father's full name
Mother's full name
Contact information:  

Address

Address (cont)

Address (cont)

City

Postal code

Work telephone
Home telephone
Cellular phone

Fax

E-mail
   
INFORMATION ON PERSON WITH PWS  

Name

Date of birth

Age when diagnosed

Who diagnosed the child?
   

Current school / workshop / residential 
situation - please specify
What is your relationship to the person
with PWS 		Parent Sibling Carer Doctor Grandparent Family
Teacher  

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